Moving and handling people in the healthcare industry

Moving and Handling People in the Healthcare Industry is aimed at PCBUs in healthcare, and aims to clarify their duties under the Health and Safety at Work Act 2015 (HSWA). It also provides advice on building and maintaining robust moving and handling systems as an integrated part of their larger health and safety management systems.

Key points

Moving and handling people in healthcare work can lead to musculoskeletal injuries and pain.

PCBUs must effectively manage the risks involved in moving and handling people.

Developing a moving and handling programme can be an effective way for PCBUs to manage these risks.

1.0 Introduction

Moving and handling people can carry a serious risk.

This guideline draws from the ACC MovingandHandlingofPeople– the New Zealand Guidelines 2012. It is aimed at persons conducting a business or undertaking (PCBUs) in the healthcare industry, to inform them of their duties under the Health and Safety at Work Act 2015 (HSWA). It offers advice on developing a Moving and Handling Programme, and what that programme should include.

This guideline includes:

an explanation of how moving and handling people at work fits into the new health and safety legislation

a PLAN-DO-CHECK-ACT approach to worker safety in the context of moving and handling.

1.1 Moving and handling people

Many countries, including New Zealand, have high injury rates among health care workers compared with other occupational groups. Health care workers have one of the highest rates of musculoskeletal disorders among all occupational groups.

Workers whose work involves moving and handling people are at risk of musculoskeletal injury. Workers who do the most moving and handling tasks each day are more likely to experience musculoskeletal injuries and pain. The use of suitable equipment, along with training and correct handling techniques, reduces musculoskeletal strain and the risk of injury among workers.

Other factors, besides the physical workload, contribute to injuries and lead to workers taking sick leave. These include:

irregular and long shifts

inadequate sleep

little control over workloads

inadequate training

incorrect equipment or use of equipment

an unsupportive work environment.

1.2 Work-related health risks and health-related safety risks

It is well recognised that work can affect a person’s health, and a person’s health can affect safety at work. Workers can become unwell or develop poor health from their work and work environment (work-related health risks). Similarly, poor health or physical and mental impairment may reduce a worker’s ability to work safely (health-related safety risks).

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1.3 Integrating moving and handling into your health and safety management system

The health and safety risks that arise from moving and handling people will be among the risks you will need to manage within your business or undertaking. Managing those risks is a part of a broader health and safety management system (HSMS) for the worksite. Where a company or organisation has operations on several sites, it’s vital to tailor systems to the needs of each.

Ensure communication is consistent for every part of your HSMS. Engage workers, health and safety representatives and other representatives in the development, and make sure they’re involved in and up-to-date with any changes to the systems.

Cover moving and handling programmes, and the rest of the HSMS, in induction, training, and regular reviews, so workers know the risks and how they’re managed. Test emergency response regularly with workers participating in evacuation processes.

Record keeping is another aspect of safety management that should be consistent across every part of your HSMS. Make sure your records are backed up off-site.

WorkSafe New Zealand encourages PCBUs to use the PLAN-DO-CHECK-ACT approach described in Figure 2.

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2.0 HSWA duties

PCBUs must ensure the health and safety of workers and other people.

2.1 Who has health and safety duties?

HSWA is New Zealand’s key work health and safety legislation. It sets out the health and safety duties that must be complied with.

All work and workplaces are covered by HSWA unless specifically excluded. WorkSafe New Zealand (WorkSafe) is the workplace health and safety regulator.

Under HSWA, everyone at a workplace has health and safety duties. There are four groups of people that have duties under HSWA – PCBUs, officers, workers and other persons at workplaces.

A positive and robust health and safety culture begins at the board table and spreads throughout an organisation. All influential stakeholders must be involved and accountable for workplace health and safety. Such a culture can add significant value. It can lead to the organisation having a good reputation for being committed to health and safety, engaged and more productive workers, decreased worker absence and turnover, and workers participating positively in risk management. Also, it can potentially deliver increased economic returns.

2.2 What is a PCBU?

A PCBU is a ‘person conducting a business or an undertaking’. It’s a broad concept used throughout HSWA to describe all types of working arrangements.

Businesses are usually conducted to make a profit (eg a business run by a retailer or a self-employed person).

Undertakings are usually not profit-making or commercial (eg a government agency or a school).

Within the health care industry, a PCBU could be any person or organisation that either directly employs or supervises, or contracts others to employ or supervise, a worker to provide private or publicly funded support, assistance and/or healthcare.

A PCBU’s primary duty of care is to ensure, so far as is reasonably practicable, the health and safety of workers, and that no other people are put at risk by its work. This is called the ‘primary duty of care’. An effective health and safety management system can help you to make sure that everyone comes home from work healthy and safe.

PCBUs also have a primary duty to provide information, supervision, training and instruction to workers. This is so that workers understand the risks they are being exposed to, and how those risks are to be managed. PCBUs also must give workers information so they can properly engage on health and safety matters.

Training includes providing information or instruction and must be easy for workers to understand.

2.3 Working with other PCBUs

More than one PCBU can have a duty in relation to the same matter (overlapping duties).

PCBUs with overlapping duties must, so far as is reasonably practicable consult, co-operate and co-ordinate activities with other PCBUs so that they can all meet their joint responsibilities. PCBUs do not need to duplicate each other’s efforts.

No one can contract out of their duties, but can enter reasonable agreements with other PCBUs to meet duties. However, all PCBUs retain the responsibility to meet their duties. The PCBUs should also monitor each other to ensure everyone is doing what they agreed.

The extent of the duty to manage risk depends on the ability of each PCBU to influence and control the matter.

For further guidance on overlapping duties see WorkSafe’s guide Overlapping duties.

2.4 Officers

An officer is a person with a specific role in an organisation (such as a company director) or a person with the ability to exercise significant influence over the management of the business or undertaking. Organisations can have more than one officer.

Officers have a duty to exercise due diligence to ensure the PCBU complies with their duties under HSWA. As part of this duty, officers must ensure the PCBU has appropriate systems in place to meet their health and safety duties, including proper delegation of officer responsibilities to appropriate and competent persons.

Officers in the healthcare sector could include:

a CEO or board member of a DHB

board directors, trustees and senior managers of any healthcare service, including volunteer services that employ staff

people holding personalised funding budgets who employ their own staff.

A person who only advises or makes recommendations to an organisation’s officer is not an officer.

2.5 Managing risks under HSWA

Risks to health and safety arise from people being exposed to hazards (anything that can cause harm).

A PCBU is expected to manage work risks effectively. You must understand how to manage any changes to work processes or organisational changes that may increase risks, and make sure any new risks are managed. You must engage with your workers and their representatives when identifying risks and making decisions on how to manage them.

Under HSWA, risks must be eliminated so far as is reasonably practicable. If a risk can’t be eliminated, it must be minimised so far as is reasonably practicable.

‘Reasonably practicable’ means doing what is reasonably able to be done to ensure health and safety, having taken into account and weighed up all relevant matters, including:

how likely the hazards or risks are to occur

how severe could the harm that might result from the hazard or risk could be

what a reasonable person knows or ought reasonably to know about the risk and the ways of eliminating or minimising it

what measures exist to eliminate or minimise the risk (control measures)

how available and suitable are the control measures(s)

Lastly, what is the cost of eliminating or minimising the risk and is it grossly disproportionate to the risk. Cost can only be used as a reason not to do something when it is grossly disproportionate to the risk.

As moving and handling people is necessary in the health care sector, it is unlikely that you will be able to fully eliminate the risks. Instead you should have processes in place to effectively manage the risk and minimise the potential for harm to occur at your workplace.

For guidance on how to manage work risks see WorkSafe’s quick guide Identifying, Assessing and Managing Work Risks.

2.6 Worker engagement, participation, and representation

Everyone at a workplace can help to make it a healthy and safe place to work. All PCBUs must involve their workers and health and safety representatives in workplace health and safety matters by:

engaging with workers on health and safety matters that may directly affect them, so far as is reasonably practicable

having worker participation practices that give workers reasonable opportunities to participate effectively in improving health and safety on an ongoing basis.

A healthy and safe workplace is more easily achieved when everyone involved in the work communicates with each other about hazards and risks, talks about any health and safety concerns and works together to find solutions.

Having worker representatives is one way for workers to participate. Well-established ways to do this include having health and safety representatives (HSRs), Health and Safety Committees (HSCs) and unions. Other representatives can include community or church leaders. Worker representatives should be elected by the workers and workers should be involved in deciding how worker engagement and representation should be organised.

Engage with workers and worker representatives:

find out how health and safety issues affect how they organise, manage and carry out their work

involve them in the decision-making process when you are identifying, assessing and deciding how to deal with work risks

encourage them to share ideas about what should be included or updated in health and safety documents

include people with a range of technical and operational knowledge and experience.

Workers’ suggestions lead to better and safer ways of working. Managers should meet employees frequently to discuss health and safety issues, and to respond quickly to the safety suggestions and concerns they raise. One way of doing this is by putting safety issues as a standard item on routine meeting agendas.

For further guidance on worker engagement, participation and representation see:

3.0 Risk identification and assessment

Planning means identifying hazards and assessing risks in a workplace, and putting in place systems to manage those risks.

The first step in risk management is to identify hazards at the site, or in the case of planning a new site, thinking about eliminating hazards through design. Look at the whole operation from a high level and work down.

You may have to work harder to identify work-related health risks, as they can be invisible and effects may take years to impact on a worker’s health.

Engage workers with a range of experiences and expertise, including HSRs, to work on identifying hazards. They need to follow a systematic approach to identify all potential hazards. Examples of identification methods include:

consulting workers with experiences and backgrounds in each area and role

inspecting the workplace

reviewing available information

asking ‘What could potentially harm a worker’s health in this workplace or through the work they do?’.

3.1 Identifying moving and handling people hazards

There are a number of different assessment methods you could employ to identify hazards related to moving and handling:

Worker assessment (individual): The capabilities of workers involved in moving and handling clients include their physical ability, training related to moving and handling, level of stress and fatigue and the number of other workers involved.

Client assessment (load): Client characteristics that can affect moving and handling risks include (but are not limited to) size and weight, level of dependency and mobility and extent of client compliance.

An example of a specific system or approach for carrying out a client risk assessment, known as the ‘LITEN UP’ approach has been used in some facilities in New Zealand since 2003 and is suitable for use where a health care provider wishes to use a specific client risk assessment system. Appendix 2 provides more detail on the LITEN-UP approach.

Task assessment: A task assessment includes identifying the specific type of moving and handling task, matching the moving and handling procedure with the load and task, and ensuring that the equipment needed for the task is available.

3.2 Assessing the risks

Once you’ve identified each hazard, PCBUs must assess the risks of it causing harm. This means assessing likelihood and consequence.

Think about:

who might be exposed to the hazard

what the potential consequences of exposure to the hazard are (eg what severity of injuries or ill-health could result? Could people be killed or develop long-term health issues?)

how likely the consequences are (eg very likely, likely or unlikely under usual business conditions).

Using the above information, plan which work risks you need to deal with first. Then decide which risks you will deal with first (eg risks with potentially significant consequences such as chronic ill-health, serious injury or death, or those with a high likelihood of occurring).

You must then decide which control measures are most appropriate. We recommend that you apply the hierarchy of controls as described below to choose the most effective control measures in your circumstances.

The first step in the hierarchy of controls is to try to eliminate risks so far as is reasonably practicable. If elimination is not reasonably practicable, the risk needs to be minimised, so far as is reasonably practicable. The hierarchy is shown below.

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Action

What is this

Example

Eliminating

Removing the sources of harm (eg equipment, substances or work processes).

Getting faulty equipment repaired or replaced.

Substituting (minimise)

Substituting (wholly or partly) the hazard giving rise to the risk with something that gives rise to a lesser risk (eg using a less hazardous thing, substance or work practice).

Replacing a piece of equipment that requires the worker to still lift some of the load with one which takes all the load.

Isolating (minimise)

Isolating the hazard giving rise to the risk to prevent any person coming into contact with it (eg by separating people from the hazard/ preventing people being exposed to it).

Isolation focuses on boxing in the hazard or boxing in people to keep them away from the hazard.

Imposing engineering control measures (minimise)

Using physical control measures including mechanical devices or processes.

Imposing administrative control measures (minimise)

Using safe methods of work, processes or procedures designed to minimise risk.

It does not include an engineering control measure; or the wearing or use of personal protective equipment.

Having emergency plans and evacuation procedures in place.

Having strong training and re-assessment systems in place to ensure workers are competent.

Managing shift work and staffing so that there are enough workers to perform tasks without fatigue or overstressing.

Using personal protective equipment (PPE) (minimise)

Using safety equipment to protect against harm. PPE acts by reducing exposure to, or contact with, the hazard.

Not typically used for moving and handling tasks unless there’s an infection risk which impacts on techniques.

Should not be the first or only control measure considered.

TABLE 1 : Defining the hierarchy of controls

4.0 Risk management

One risk may need multiple control measures to adequately manage it.

Once planning and assessment are complete, it’s time to put in place the control measures. If elimination is not practicable, you need to minimise that risk, so far as is reasonably practicable.

If elimination is not possible, work your way down, starting with substitution then isolation and so on, and discarding solutions if they are not reasonably practicable. Minimising could mean choosing more than one of the following actions that is the most appropriate and effective way to control the risk:

substituting with a lower risk activity

isolating people from the hazard/preventing people being exposed to the risk

applying engineering control measures

administrative control measures, including:

training

resource management

regular equipment maintenance.

4.1 Moving and handling programmes

A moving and handling people programme takes policy into practice by creating processes and procedures by which the risks will be managed. Moving and handling programmes should include processes for incident and injury investigations and follow up action such as improved control measures (eg retraining workers, modifying facilities, and acquiring additional equipment) and programme evaluations.

Moving and handling programmes significantly reduce the rates of injury resulting from client moving and handling, as well as the associated costs. Programmes that are successful in reducing injuries to health care workers need multiple components, such as support from management, an appropriate policy and management commitment, facility design, equipment, risk assessments, training, auditing, and reviews. There are also financial savings through lower costs from injuries, reduced worker absenteeism and turnover, and efficient work processes.

Each facility needs to develop its own programme that can be easily conducted and clearly communicated to all workers involved in moving and handling people.

Training workers in people moving and handling techniques alone is ineffective in reducing injuries. Only a moving and handling programme with multiple components is effective in reducing back problems and other injuries among health care workers.

4.2 Core components of moving and handling programmes

Moving and handling programmes should include:

a policy on moving and handling people

facilities that are designed or modified for moving and handling people

clear allocation of health and safety responsibilities

work organisation and practices changed (eg developing a culture of safety, adequate staffing and work allocations that avoid repetitive work and long hours)

risk assessment protocols, documentation and an incident reporting system

worker management processes including training and assessment

equipment management

provision and maintenance of moving and handling equipment

client management procedures from initial assessment to discharge/end of care.

4.3 Policies

The reason for developing and using a moving and handling policy is ultimately to reduce the risk of injury to workers and health care clients. Having such a policy helps to create a workplace culture where workers are trained, equipped and supported to always use safe moving and handling techniques and equipment.

A moving and handling policy should be part of an organisation’s broader set of health and safety policies, and should be integrated with existing business strategies and policies, for example those covering health and safety for both clients and workers, and the quality of health care for clients.

Once you have identified key moving and handling risks, consider developing high level policies for each. These should be clear statements of commitment to managing the risks, and include broad aims and performance targets for each one. Each policy should be reinforced through periodic review and involvement of management.

4.4 Taking the lead

Senior management need to be ‘visible’ in providing strong leadership for workplace health and safety. They must also understand that they cannot contract out of their duties under HSWA. Leadership includes support for the promotion of a safety culture generally, and specifically where workers are encouraged to raise issues and participate in solutions. This includes:

ensuring there is a health and safety representative in the organisation

providing resources for equipment and resources that reduce workplace hazards and risks

involving workers in safety reviews and decisions.

Other roles for management include:

establishing high standards of performance for moving and handling programmes

ensuring the operation of rosters and work shifts does not compromise safety

providing timely responses to safety incidents and concerns in a constructive manner

regularly communicating information on safety performance indicators

putting in strong recruitment and procurement systems.

Management and workers need to be up to date with developments in equipment design and application and other physical resources for workers, including PPE and the design of workplaces. For reducing hazards in moving and handling, there are ongoing developments in equipment and facility design.

Management needs to ensure that workers or managers with health and safety responsibilities keep up to date with these advances and provide input into upgrading equipment and facility design. Changes and progress should be communicated clearly throughout the business or undertaking.

In large organisations, there are likely to be established teams or managers with overall responsibility for monitoring health and safety operations across the entire organisation. Health and safety managers need adequate resources as they need to be an integral part of the organisational culture of safety. The managers should provide input into all training programmes to ensure hazard identification and workplace safety are included.

Other key roles for health and safety managers are meeting workers frequently to discuss safety issues, and responding quickly to safety suggestions and concerns raised by workers.

In small organisations, specific individuals may be given responsibility for workplace health and safety. In this case, all workers should know who those people are and that they can be consulted by anyone.

Engaging people to manage health and safety, or assigning it to specific people does not detract in any way from the PCBU’s duties or officers’ obligations – those duties cannot be delegated or contracted out.

4.5 Facility design

Designing accessible, fit-for-purpose spaces will go a long way towards managing the risks in moving and handling people.

Whether planning a new facility or undertaking minor renovations or a major upgrade of an existing facility, there are opportunities to consider moving and handling issues. For facilities with limited resources, and for home based care, upgrading existing facilities is often the most feasible option to make existing workspaces safer for both clients and workers.

There are also likely to be other benefits, such as improvements in the quality of care, increased worker morale and decreased associated costs. There are also potential benefits for clients.

NZS 4121 Design for Access recommendations are not suitable for dependent disabled people who require assistance from one or two workers. For example, the bathroom recommendations are too small to allow sufficient space for workers and moving and handling equipment.

The New Zealand Ministry of Health generally requires use of the Australasian Health Facility Guidelines (Australian Health Infrastructure Alliance, 2009) for buildings and facilities for DHBs.

Assessing existing spaces for upgrading

A key phase in building and facility renovations is to carry out a review and assessment of the existing spaces in terms of their suitability for moving and handling. The main features relevant to assessing existing spaces for building renovations are likely to include:

future proofing the facility for changes in types of client or facility use.

New building design

Ceiling track speciifed

Minimum width specified for doors and corridors

Client rooms

Bathroom design

Equipment storage

Areas for bariatric clients

Renovating or upgrading an existing facility

May range from specific and relatively minor modifications to major changes, possibly including structural changes

Doorways widened

Bathroom redesigned

Ceiling tracking installed or retrofitted

Equipment storage added

Access for mobile hoists

Ramps to doroways

Grab rails

TABLE 2: Opportunities for improvement

Facility design process

With any facility development, it is important to use a systematic approach so that physical spaces needed for moving and handling people are given adequate consideration. Effective consultation between the business, designers, (eg architects) and end users (clinicians/workers/consumers) should be a part of this approach.

Design features

The design of all health care facilities should enable independent mobility by clients and allow workers to work with clients in ways that reduce risks to clients and workers. Effective moving and handling places additional design requirements on facilities. Extra space is needed for workers to work alongside clients and to allow suitable equipment to be used. How much extra space is needed depends on the number of workers required, the level of mobility of clients, the equipment being used and the specific techniques used to move people, and possible changes in the profiles of clients in the facility or unit.

Areas for consideration include:

corridors

floor spaces for passing and turning

minimum turning spaces

doorways

flooring

ramps

handrails

bedrooms

toilet spaces

shower rooms

combined shower and toilet rooms

rooms with baths

day and dining rooms

clinical suites

other client handling areas, including:

lifts in multi storey buildings

external access to buildings

outdoor areas such as gardens

worker and client call systems.

4.6 Staffing

Ensure you have enough workers to perform necessary moving and handling tasks, to minimise the risk to them. Make sure workers are physically able to undertake the tasks they are employed to do – this could be a factor in recruitment. Re-assess workers if their health changes. For example, following injury or if their physical condition changes.

Many moving and handling tasks require more than one worker. It’s vital that adequate staff are employed and rostered on, or workers may attempt those tasks alone, seriously increasing the risk of injury. It’s also important to have enough workers to accommodate leave being taken. Overworked workers are at risk of fatigue, which can increase the risk of injury.

4.7 Training

Workers must be trained to safely perform moving and handling tasks, to minimise the risk that those tasks could injure themselves or their clients. Trainers should be able to demonstrate competence in the area of manual handling, with recognised training credentials.

Effective systems for training workers are crucial for developing a culture of safety. Training programmes and workshops should cover the range of technical skills needed to identify hazards and risks in the workplace and the use of procedures that reduce those risks.

Why is training important?

Training is a vital part of implementing moving and handling because it:

provides information about policies and protocols for moving and handling

teaches workers how to identify and assess client moving and handling risks

provides workers with the skills they need to manage the risks

supports professional growth by developing staff knowledge and skills

encourages workers to take personal responsibility for safety in the workplace

helps PCBUs and workers to meet their legal responsibilities

enhances client safety and preserves their dignity.

Training should be comprehensive and cover organisational policies, risk assessment and documentation, handling techniques and use of equipment. Where feasible, training should be tailored to participants’ knowledge and awareness of risks, and their specific work environments.

The training needs of workers in aged care in the community should not differ from those in acute hospitals. Aged care workers, whether community based or within a public health facility, require training programmes that address their specific moving and handling tasks. Home care and community organisations need to consider the additional issues in implementing good moving and handling systems in their environments. They could consider organising their own training programmes using the assistance of external providers to provide the expertise and support required.

Who needs to receive training?

Training should be required for all workers directly involved in moving and handling people, as well as their managers and supervisors. Workers directly involved in moving people include, but are not limited to, nurses, physiotherapists, occupational therapists, medical staff, ambulance staff, and people working with the disabled and aged in the community. Consider also training staff who would normally not be involved in moving and handling people, because they might need to assist in special situations.

When is training needed?

Training should be provided in the following instances:

when a new worker starts, if their work requires them to move and handle people

when courses for existing workers who have already attended orientation training in moving and handling need updating

when new equipment or work practices are introduced

when a worker is transferring from one area of care to another

as remedial action following an incident or near miss

for workers in areas that require techniques or equipment that are more specialised, for example, care of clients with spinal injuries.

Core competencies in moving and handling training

The purpose of training workshops is to provide workers with practical skills and knowledge to reduce the risks involved in moving and handling in the workplace. The core components of training should cover:

practical skills – including completing risk assessments, techniques used for sitting and standing, bed mobility, lateral transfers, and hoists and other equipment for moving and handling people.

Appendix 3 shows an example of what a day-long training session could include.

Training session outcomes

At the conclusion of a training session, keep a record of each trainee’s attendance and outcome, and provide a certificate that verifies their participation in training.

Trainees should be assessed on the knowledge and skills taught in the session by the trainers. Trainees can also do self assessments or peer assessments of their skills.

Evaluation of training sessions and workshops

Trainers should routinely gather feedback from trainees so that the person coordinating training and the trainers can assess the effectiveness of the training sessions. This can be done using a brief evaluation form handed out to participants at the end of the training session.

4.8 Equipment

Equipment is a core component in effective moving and handling programmes, together with risk assessments, the use of correct techniques, staff training and appropriate facility design. The supply of equipment by itself will not lead to reduced rates of injury unless equipment use is part of a comprehensive moving and handling programme. Successful programmes provide both equipment and training in how to use specific items of equipment for lifting, transferring and repositioning people.

The proper use of equipment is essential for the safety of both clients and workers and improves the quality of client care. Equipment can also facilitate client rehabilitation, decrease morbidity and preserve the dignity of clients. Compared with techniques that involve manual transfers of people without equipment, the use of equipment lessens the forces required for moving and handling people and can reduce the risks.

Moving and handling equipment also improves client outcomes, such as reducing their length of stay and the risk of secondary complications such as deep vein thrombosis, pressure ulcers, skin tears and falls. That said, incorrect use of safety equipment can actually contribute to injury, so training should include equipment use.

Good equipment management should include processes for:

equipment procurement

storage

equipment maintenance

replacing and upgrading

disposing of equipment.

Appendix 4 provides an example of an equipment register.

4.9 Client assessment

Control measures need to be tailored to each person in care, as each will have different needs. An initial client assessment means that workers have information on the person’s needs, and how best to address moving and handling them.

Assessing a client’s mobility and the transfer tasks needed is the first step in the care and rehabilitation process. The purpose is to identify the risks, goals and resources needed as part of the risk reduction process. Workers may be faced with unplanned situations that can increase the risks for client and worker. The assessment process balances the risks and needs of the client with the available resources. It is important to begin the assessment as part of the admission and schedule regular updates.

Assess a client’s ability to assist during repositioning, transferring and moving. Where possible, use hoists or moving and handling aids to perform moving and handling tasks.

As the person’s care progresses, it’s important to periodically revisit the initial client assessment, and to update it as needed. Appendices 5 and 6 provide examples of client and mobility assessments.

Bariatric care

In the past 20 years there has been an increase in the number of bariatric admissions to health care facilities. The increasing number of bariatric clients presents a challenge to health care and other service providers to give care that is effective and safe for both the clients and workers.

Bariatrics is the science of providing health care for those who are severely obese. Several criteria are used to determine if someone is classified as a bariatric client, but there is no consensus on those criteria. Examples of criteria that are used include those people:

with a body weight greater than 140 kilograms

with a BMI greater than 40 (severely obese), or a BMI greater than 35 (obese) with co-morbidities

with restricted mobility, or who are immobile, owing to their size in terms of height and girth

whose weight exceeds, or appears to exceed, the identified safe working loads (SWLs).

The complexities of bariatric care should be anticipated and planned for. Bariatric care should be included in moving and handling training, equipment rated for bariatric patients should be available when needed, and emergency planning should take into account the possibility of bariatric clients in evacuation procedures.

4.10 Task assessment

With the client assessment as a baseline, the next step in controlling the risk of moving and handling injuries is to assess each moving and handling task before it commences.

There should be a systematic risk assessment before any moving and handling of a client, to identify risks and organise control measures. Identify tasks that require lifting, lowering, carrying, pulling, pushing and supporting. When a decision has been made that a client should be moved, the worker needs to carry out the specific procedures relating to the client, the worker (or workers), the task and the environment in which the task will take place. These detailed risk assessments are primarily relevant for inpatients or people receiving ongoing care.

Workers who have only brief contact with clients, for example ambulance and fire service, could use briefer checklists or assessments. However, a systematic assessment approach should be taken even in brief contact in order to manage risk.

Consultation with other professionals may be needed regarding the client’s physical function and strength.

4.11 Incident reporting

Having a robust incident reporting process is key to identifying where control measures aren’t adequate, and promote a culture of improvement.

Management should use the reporting of incidents, errors and near misses as learning opportunities for both workers and management, and to indicate steps that can be taken to improve on safety performance. It is important to communicate to workers the findings and actions taken following an investigation.

Incident reporting systems generally involve:

routine reporting and recording of specific events, such as minor incidents, near misses and equipment failures

incident and injury records containing key information about injury events, including the nature of the injuries, the hazards present in the setting where the injuries occurred, and the tasks being performed at the time of injury

analysis of reported incidents to pinpoint potential or actual failures in safety systems

documenting trends in incident data over time.

Incident forms can be used to record specific events, including accidents and other incidents. These forms can be adapted to identify events occurring while moving and handling people. For example, when recording the work activity at the time of the incident, add a specific category (eg a box that can be ticked) for any incident that occurred while moving and handling a client. There should also be forms available for early reporting of discomfort and pain occurring during workplace activities. Appendix 7 shows an example of an incident report template.

You must notify WorkSafe when certain work-related events occur. More information on notifiable events can be found on the WorkSafe website.

4.12 Emergency plans

No matter how robust your systems and procedures are, everything changes in an emergency situation. Therefore it’s vital to include an emergency plan in your HSMS.

In the context of moving and handling, it’s vital that the emergency plan takes into account the mobility restrictions of clients. Hospitals and emergency services need to establish protocols and specific arrangements for moving and transporting people in an emergency. Those protocols should be covered in training, and communicated to all workers.

Emergency plans must be maintained, and should be tested at least yearly, and whenever there are changes to the work place or safety systems.

5.0 Monitoring and audits

Ongoing review will show whether your moving and handling programme is working.

The final step in the process of managing exposure to the risks associated with people moving and handling is to monitor and audit the effectiveness of control measures. This is necessary to make sure the systems are working as intended.

Monitoring assesses the extent to which organisational systems and control measures are working and ensures they are implemented systematically throughout the workplace. It is important to consult a range of workers, particularly those who have worked with the control measures.

A specific part of programme review is to conduct audits of risk assessment procedures. An audit refers to a performance review intended to ensure that what should be done is being done. Where there are gaps, an audit should provide information that enables improvements to be made.

These checks can be part of the larger auditing systems in place, or self- contained, but integration tends to support consistency and thoroughness.

5.1 Sustaining an effective moving and handling programme

A common experience following the setting up of new initiatives in the workplace is that they become less effective over time as workers change, and systems revert to the previous styles of operation. After the successful launch and implementation of an injury prevention programme, management may reduce funding and resources, and the programme may become less effective.

For the successful sustainability of moving and handling programmes in New Zealand, some key themes are likely to be:

continuing development and updating of moving and handling programmes

having a local champion or advocate for moving and handling in every facility involved in moving and handling people

establishing strategic links with key groups and organisations, including regional linkages for moving and handling coordinators

integrating moving and handling with other systems within an organisation, including other health and safety programmes, training programmes, audits, and performance targets

ensuring programme continuity during turnover in management and workers.

5.2 Developing monitoring systems

Monitoring is an ongoing process that involves collecting, recording, summarising and reporting information related to the implementation of a programme and its outcomes. Monitoring should be a routine part of effective management systems, and the information extracted helps to identify whether performance is good or bad, and why. Consistent and thorough monitoring:

enables a better allocation of resources

enables better client and patient safety

supports worker safety

helps to avoid incidents and events that detract from core operations

assists strategic planning for future developments and increased efficiencies in services and programmes.

When a new moving and handling programme is implemented, or following significant changes to an existing programme, monitoring is essential to get a picture of how well the programme is working, and whether modifications are needed to improve the programme. For some organisations, it will be appropriate to include monitoring into broader organisational monitoring systems as part of health and safety operations.

For others, it will be easier to set up specific monitoring systems for moving and handling, and appoint a coordinator or manager to operate the monitoring system. Whichever patterns suits, setting up a monitoring system is essential to keep track of a programme and make sure it is working properly. A monitoring system will also provide information for more comprehensive reviews and evaluations of the programme later on.

Examples of information that might be used for monitoring include:

existing reporting systems, including statutory reporting

number of workers attending moving and handling training

proportion of total workers who have attended training

hazards and other items discussed at health and safety meetings (meeting minutes)

5.3 Setting up a monitoring system

The first step in setting up a monitoring system is to identify moving and handling information that is already collected. This information may be held in several locations or databases within an organisation. Develop a list of these information sources and a plan for how the sections relevant to moving and handling could be integrated into a single data set.

Once the relevant information has been compiled, find out whether its usefulness for moving and handling could be improved by making small changes to the way it is being collected. For example, if incidents or minor injuries are recorded, could additional information about activities taking place be collected so that it is clear whether incidents or injuries occur during moving and handling activities?

The next step in setting up a monitoring system is to plan what additional information needs to be collected to maintain an overview of how well the moving and handling programme is working. Two main types of moving and handling data that should be collected are incidents and audits. Where possible, arrange to combine any new data collection with existing data collection systems to minimise the costs of collecting additional data.

5.4 Evaluation of moving and handling programmes

Monitoring a moving and handling programme is a useful precursor to developing an evaluation of programme outcomes and the extent to which the programme is producing the intended effects. For moving and handling programmes, the intended effects are likely to be reduced discomfort and pain among workers, fewer injuries and fewer days off work by workers.

You should typically use monitoring information as a starting point and extend the information to build a comprehensive view about how well the programme is being implemented. If there is little or no monitoring or audit information available, a process evaluation will need considerable additional time and resources to gather the information required.

5.5 Developing evaluation indicators

A primary purpose of an outcome evaluation is to determine the extent to which the negative outcomes, such as injuries, ACC claims and staff absence, have decreased in the time since the moving and handling programme was implemented. Data collected for the outcome indicators require collation, statistical analysis and reporting so that any trends in the outcome data are clear. The use of trends for 12 month periods has been suggested above.

However, trends can also be combined and reported for other time intervals.

One common problem is that existing monitoring data are not able to be separated by outcomes related to moving and handling, and outcomes related to other activities. For example, worker sick leave and absence records may not include the reasons leave was taken. Also, some musculoskeletal strains worsen over time, and may be the result of a number of events or tasks, rather than a particular incident.

Specific measures that could be used as outcome indicators in an evaluation include:

number of injury events that resulted in days away from work

number of days away from work due to a work related injury

number of days on restricted work or transfer to another role when a work related injury keeps a worker from performing their routine job functions

incidents requiring medical treatment beyond first aid

number of days of sick leave taken by workers in a work group or unit.

It will be important to ensure that any data collected are labelled or tagged by the task being performed at the time of injury, so that injury events can be sorted or stratified as ‘moving and handling’ injuries or ‘other’ type of injury.

5.6 Audits

In contrast to ongoing monitoring of systems and process throughout their use, audits are discreet thorough reviews of all or part of the programme. This could be scheduled yearly or every two to three years. Audits usually use audit checklists that record observations of specific items or activities to determine if they comply with the patterns expected in a programme.

Whoever carries out an audit should plan to communicate the audit findings to the unit managers with the intention of improving worker performance and safety, the care and safety of clients, and the work environment overall. It is important to consult a range of workers. Workers should also be informed of the findings in a manner that does not spotlight individuals, especially if there are issues of non compliance.

The outcomes from audits enable managers to assess how well moving and handling programmes are working. They also gauge the level of compliance by workers with expected practices for moving and handling. Audits should also identify potential areas of concern, and validate and review information or data for completeness and accuracy. Audit information must be documented and communicated back to the manager or supervisor of that area, so safety for clients and workers can be maintained, and to address specific issues or potential issues identified.

Types of audit

These include routine or scheduled audits, spot or random audits, and audits in response to adverse outcomes. Audit information is collected using one or more procedures such as:

observing workers at work

interviewing workers

checking client profiles or records (eg risk assessments)

interviewing clients

walkthrough audits to check equipment.

Routine or scheduled audits are planned at regular intervals to obtain estimates of compliance levels with moving and handling practices. The frequency of scheduled audits depends on the availability of resources, and whether audit information is needed to assist in decision making at specific times during the year.

Spot and random audits are unscheduled audits, usually initiated by health and safety managers or moving and handling coordinators, and may be used to target areas with high incident rates. Spot audits are typically performed to ensure compliance in areas where the need for compliance is high. Ideally spot audits should be conducted regularly during the year and, when the need arises, information from spot audits can be used by managers to decide whether immediate action is needed to avert any potential problems.

Spot audits may involve observing workers conducting moving and handling tasks, such as risk assessments, transfer techniques, and using equipment such as hoists and slide sheets. Client records such as client profiles can be checked against their mobility levels to determine whether risk assessments are accurate.

Adverse outcomes audits are carried out following specific injuries or incidents to determine whether there are particular patterns of client transfers related to incidents, staff absence or sick leave. These audits are generally conducted by senior managers. It is important to look for underlying reasons for higher rates of injury and absenteeism, and areas where serious incidents have taken place, even if they were isolated cases. It may also be useful to focus on areas that have recorded falling rates of injury or absenteeism, because there may be lessons to be learnt from these trends.

Comprehensive audits may be carried out as part of major evaluations of moving and handling programmes in multiple facilities and workplaces. Often such audits are organised by regional or national authorities to provide overviews of moving and handling programmes in health and residential care facilities. Such audits have been used in Australia and in other countries that have national or federal agencies responsible for health and safety in workplaces.

Who carries out audits?

Routine audits are usually conducted by unit managers, supervisors or moving and handling coordinators. Occupational health and safety managers or representatives usually organise audits, and have overall responsibility for collating and analysing audit records, reporting audit outcomes and determining overall compliance with organisations’ moving and handling policies.

Unit managers or supervisors can delegate spot audits to workers, rotating them during the year so everyone participates in audits. It is useful for workers to audit different wards or units from their own work areas. Community and district carers should also be included.

Community workers also need to be audited. As there may be resourcing issues with organisations and people providing services to those living in the community, home workers need to have access to people suitably qualified to carry out audits if expertise is not already available.

Areas to audit

Risk management

Risk identification varies by setting and may be different in hospital wards, acute care, aged care, nursing homes and home care. When conducting a risk assessment audit, the following information sources can be considered:

What information is kept about the profile of clients?

What forms or checklists are used for risk assessment?

What central records are kept relating to client profiles?

Is the client mobility assessment card visible near the client’s bed?

What movement risk assessments are conducted before moving people?

PRACTICAL TECHNIQUES

Gathering information for technique audits is generally more complex and time consuming than for other components of moving and handling programmes. Relevant information can be gathered in several ways:

by the observation of ongoing moving and handling tasks in a work unit

through asking workers to carry out specific transfer tasks with clients or other people

through surveys where workers report on how they carry out moving and handling tasks.

Where non compliance has been reported for specific moving and handling techniques (such as the use of hoists, slide sheets and other equipment), an auditor may wish to use informal interviews with workers to find out reasons for the non compliance.

Information from informal interviews can be used directly to plan specific training for the workers, and to find out if any changes are needed to remove barriers to compliance. Auditors should check if the necessary equipment is readily accessible and available to workers.

Audits of techniques should be carried out by workers or managers with relevant training and experience in moving and handling people.

TRAINING

Audits of training cover the extent to which workers involved in moving and handling people have adequate training. Training audits should be one of the easier types of audits to conduct, providing suitable records of training have been kept. Training records include:

lists of workers who have attended training, held by trainers

lists of workers from specific wards or units who have attended training, held by managers

lists of workers who did not attend their scheduled training sessions

training programme documents, such as the training schedule and topics covered in training

assessments of trainee competencies made by trainers

participant evaluations of training workshops held by trainers

training providers and trainers engaged.

Two specific areas of training that should be monitored and audited by unit or ward managers are induction training for newly employed workers, and annual updates or refresher training for existing workers. Unit managers need to monitor the training schedules for workers in their groups and arrange for workers to be released for training.

EQUIPMENT

Generally, the managers of units responsible for storing and using equipment will be responsible for auditing equipment. Shared or pool equipment may need specific arrangements for auditing. Equipment audits should cover the availability of equipment within the unit or ward that is suitable for the client profile of the unit.

Important features for an equipment audit include the following:

Availability: Are there sufficient items of each type of equipment available where needed?

Equipment storage: Can the equipment be stored in a suitable place when not in use?

Ease of access: Are equipment items stored in places that make it easy for workers to access them?

Proper labelling: Are fitness certificates and SWLs clearly labelled on hoists and other equipment?

Maintenance and servicing: Do visual checks of equipment identify any problems or potential problems (eg wobbly wheels on wheelchairs, tears in slings, infection control issues)?

FACILITY

Facility audits cover building design, workspaces and furniture related to moving and handling and should take place at least once a year. A facility audit should also take place after an incident or near miss, and before a facility or area is to be upgraded or renovated. Auditors should pick specific areas to do walkthrough observations with a list of items to check.

Walkthrough audits can be effective as a straightforward way of checking on storage, facility layout and some risk assessment details. A walkthrough audit can quickly pinpoint problems related to storage space, lack of access to equipment and poor facility design.

6.0 Continuous improvement

6.1 Continuous improvement

It’s important to act immediately to improve control measures and processes whenever problems are identified, or when the opportunity to upgrade is presented. Good ongoing monitoring and scheduled whole-of-programme audits will help with this. Schedule additional checks after changes have been made to the workplace, or systems. Revise your programme and control measures whenever monitoring indicates an opportunity to do so.

A commitment to continuous improvement will have knock-on positive effects on your workplace culture. Where workers can see that management is invested in their health and safety, communication and practice will often improve.

6.2 Learning from incidents

Following analyses of incidents, information concerning the causes of near misses and adverse events can be used to plan changes that reduce the risk of incidents and improve safety. Information on the frequency of specific types of failure and near misses and current safety performance can be communicated to workers to increase awareness of current operational risks and remedial measures. The training coordinator for moving and handling should be involved in incident reporting analyses so that alerts and incidents can be included in training programmes provided for workers.

6.3 Learning from people

Often the best way to test the effectiveness of your moving and handling programme is to speak to the people directly involved in it. Workers performing moving and handling tasks are best equipped to report on whether the programme is working, and how it could be improved. Regular feedback should be sought, either in person, through representatives, or through consultation mechanisms like surveys.

Similarly, clients and patients could provide valuable insight as to whether their needs were met while they were being cared for. Exit interviews when a patient is discharged, or carer reviews for those under at-home or residential care should be a part of the monitoring processes, and opportunities for improvement taken.

6.4 Learning from audits

Once the results of an audit are available, and areas for improvement have been identified, endeavour to start those improvements as soon as possible. Ensure health and safety workers and representatives are involved, as well as workers in the areas needing improvement. The best people to action positive change are those who will be affected by it.

Appendices

Appendix 1: Key health and safety terms

You can use these terms and explanations to help build worker understanding. For more information about these and other terms see definitions and accronyms.

Term

Explanation

Business or undertaking

The usual meanings are:

business: an activity carried out with the intention of making a profit or gain

undertaking: an activity that is non-commercial in nature (eg certain activities of a local authority).

Competent person

A person who is appropriately trained, skilled, knowledgeable and/or experienced to safely complete a task.

Control measure

A way of eliminating or minimising risks to health and safety.

Duty holder

A person who has a duty under HSWA (see explanation below). There are four types of duty holders – PCBUs (see explanation below), officers, workers and other persons at workplaces.

Eliminate

Remove a hazard.

Engagement

A PCBU (see explanation below) has to engage with its workers on health and safety matters. A PCBU engages by:

sharing information about health and safety matters so that workers are well-informed, know what is going on and can have a real say in decision-making

giving workers reasonable opportunities to have a say about health and safety matters

listening to and considering what workers have to say

giving workers opportunities to contribute to the decision-making process relating to a health and safety matter

considering workers’ views when decisions are being made

updating workers about what decisions have been made

involving any HSRs.

If workers are represented by an HSR, engagement must involve that representative.

Hazard

An actual or potential cause of harm, including an object, activity or event. Includes a person’s behaviour where that behaviour has the potential to cause death, injury, or illness to a person (whether or not that behaviour results from physical or mental fatigue, drugs, alcohol, traumatic shock, or another temporary condition that affects a person’s behaviour).

Health and safety committee (HSC)

An HSC supports the ongoing improvement of health and safety at work. An HSC enables PCBU representatives, workers and other HSC members to meet regularly and work co-operatively to ensure workers’ health and safety.

Health and safety representative (HSR)

HSRs are workers elected by members of their work group to represent them in health and safety matters.

Investigation

A process of gathering information about an accident or incident to find out why the accident or incident happened and how to stop it from happening again.

Minimise

Reduce the risk of a hazard occurring when workers are exposed to it, if eliminating or isolating it is not possible. For example, wearing PPE reduces the risk of exposure to blood borne viruses.

Near miss

An incident which did not result in injury, illness or damage, but potentially could have.

Notifiable event

A notifiable event is when any of the following occurs as a result of work:

a death

notifiable illness or injury (see below)

a notifiable incident (see below).

Under the Health and Safety at Work Act 2015 (HSWA) you must notify WorkSafe when a notifiable event occurs. See HSWA sections 23 and 24 for more information.

Notifiable injury or illness

An injury or illness that requires the person to have immediate treatment (other than first aid). For example, a serious head injury, a serious burn, an injury or illness that requires, or would usually require, the person to be admitted to a hospital for immediate treatment or to have medical treatment within 48 hours of exposure to a substance.

Notifiable incident

A notifiable incident means that someone has been exposed to a serious or immediate risk to their health and safety because of an unplanned or uncontrolled work incident.

Officer

An officer is a person who has the ability to significantly influence the management of a PCBU. This includes, for example, company directors and chief executives.

Officers must exercise due diligence to ensure the PCBU meets its health and safety obligations. See WorkSafe’s special guide Introduction to the Health and Safety at Work Act 2015 for a detailed explanation of an officer’s role and duties.

Other person at workplace

Other persons include workplace visitors and casual volunteers (who are not volunteer workers). Other persons at workplaces have their own health and safety duties to take reasonable care to keep themselves safe and to not harm others at a workplace.

Overlapping PCBU duties

When more than one PCBU has health and safety duties in relation to the same matter.

PCBU

PCBU stands for ‘Person Conducting a Business or Undertaking’. In most cases a PCBU will be a business entity, such as a company. However, an individual carrying out business as a sole trader or self-employed person is also a PCBU.

Personal protective equipment (PPE)

Anything used or worn by a person (including clothing) to minimise risks to the person’s health and safety.

An organisation that supports its membership by advocating on their behalf. The Employment Relations Act 2000 gives employees the freedom to join unions and bargain collectively without discrimination. Workers can choose whether or not to join a union.

A union is entitled to represent members’ employment interests, including health and safety matters.

Appendix 2: Example of a risk assessment system: The LITEN UP approach

This appendix describes an example of a specific system or approach for client risk assessment, known as the ‘LITEN UP’ approach. LITEN UP has been used in some facilities in New Zealand since 2003. It is suitable for use where a health care provider wishes to use a specific client risk assessment system.

The purpose of LITEN UP is to ensure that client handling is safe for both workers and clients. Risk can be assessed using the LITE principles outlined below in conjunction with suitable assessments of client dependency. The LITE principles, combined with client profile information, provide the information needed to make decisions about safe client handling.

The lite principles

LITE is a way to remember the key risk factors that should be considered when preparing a safe client handling strategy. The LITE principles are described in the table below.

Individual refers to workers who are moving the client. It includes the workers’ knowledge, training, general health and fatigue that can affect one’s ability to do the job.

Task

Task refers to the nature of the moving and handling task to be done, how and when. Different tasks have different challenges. Each moving and handling task needs assessment and a specific strategy.

Environment

Environment means the working environment, and covers factors such as space, equipment availability, staffing levels, work culture and resources, which all impact on how the task can be done.

In the LITEN UP approach, risk factors are not necessarily assessed in the order shown, and not all risk factors need to be completely reassessed in every situation. In most wards or units the ‘Environment’ and ‘Individual’ factors can be assessed by workers (or other people who are trained in risk assessment) and applied to most client handling situations. Generally, workers must consider all four LITE principles before selecting a handling technique and organising any equipment required. Check the information in the client profile, related to risk assessment, prior to moving the client to ensure appropriate handling procedures are used.

The LITEN-UP approach is based around three key steps – review, plan, and action. This is very close the Plan, Do, Check, Act cycle of continuous improvement that WorkSafe advocates.

Date, where disposed to and people informed about disposal (if needed).

Equipment replacement

Details about new equipment to replace equipment disposed of.

Appendix 5: Example of information included in a client profile

Appendix 6: Examples of mobility assessment tool

These are two examples of mobility assessment tools; the HASI model and the Patient Movement Classifications. Both allow simple classification of a client’s mobility into categories that support decision making around moving and handling techniques to employ. A moving and handling programme should include clear definition around client assessment, including the tools used for classification.

An account of the incident from perspective of the person affected, a witness or other person.

Type of incident

A set of categories that provide summary classifications of the incident, such as discomfort, pain, near miss incident, first aid incident, medical treatment required, time off required.

More than one item may be ticked.

Activity at time of incident

Type of work or other activity in which person affected was engaged when the incident occurred. If desired, specific tick boxes can be added to assist classification, such as ‘moving and handling client’.

A description of the factors that are likely to have caused the incident (eg environment, organisational system, individual factors, patient, equipment etc). If the cause is not clear, state ‘cause unclear’.

Follow up required

Comment from person filling in form (or a supervisor) as to whether any further investigation or follow up action is required in relation to the incident.

Referral to health and safety

Confirmation that a copy of the completed form is being sent to the occupational health and safety section and other people if relevant.

Sign off

Signature of person filling in form and date of completion of form.

Note: The suggested fields in this table are commonly included in incident report forms. Each organisation should develop its own form to suit the organisational requirements.